Mary-Frances McCafferty and Catherine Lee
Mindfulness Based Cognitive Therapy (MBCT) is a group-based treatment which simultaneously combines mindfulness practice with elements of Cognitive-Behavioural Therapy. Previous literature suggests that there is limited research investigating the benefits of MBCT for older adults; despite preliminary evidence suggesting cognitive, emotional, physiological and psychological benefits. This study aimed to add to and address this gap in the literature by exploring the experiences and perceived benefits of MBCT as a therapeutic intervention for adults (N=7) who attend an older adult mental health service. The study employed a repeated-measures, mixed-methods design. The quantitative phase examined older adults’ perceived levels of depression, self-compassion, stress, mindfulness use and quality of life.
Administration of measures at baseline and following eight weeks of MBCT indicated improvements across all areas. The qualitative phase employed semi-structured interviews and used thematic analysis to examine older adults’ experiences of participating in the group. Participants retrospectively viewed their experiences positively, and highlighted their perceived benefits of engaging in an MBCT group. Post-group, participants reported continued mindfulness use, both regularly and as a responsive technique. Findings suggest that MBCT may be a beneficial psychological intervention for older adults. Recommendations for further research and practice are discussed within the context of therapeutic interventions for older adult mental health service users.
The act of being mindful is purposefully paying attention to our lives: moment by moment, on purpose and without judgement.1 Mindfulness develops a connectedness between the mind and the body, and focuses on an individual’s abilities as opposed to difficulties, making it an empowering activity. Mindfulness evolved from the Buddhist tradition of meditation, is over 2,500 years old and is secular in nature. Research shows that the average person spends only 53% of their time in the present moment, with the remainder spent ruminating about the past or focusing on the future.2Mindfulness increases our capacity to bear witness to internal pain.
Treatment options for recurrent depression in adults under the age of 65 recommend MBCT.3MBCT is a group based treatment which simultaneously combines mindfulness practice with elements of Cognitive-Behavioural Therapy (CBT).4There is evidence that MBCT is an effective treatment for depression relapse prevention, with studies showing its effectiveness for those who have experienced three or more episodes of depression.5,6MBCT has also shown benefits for adults currently experiencing depression 7and has been associated with an increased quality of life.8
Previous literature suggests that there is limited research investigating the benefits of MBCT for older adults despite preliminary evidence suggesting cognitive, emotional, physiological and psychological benefits.9Older adults can face various difficulties associated with the ageing process, such as health concerns, bereavement and social isolation.10Mindfulness training has been suggested as a powerful approach to ageing healthily.11When practised correctly, it can reduce personal suffering for each individual, including those experiencing acute psychological problems.12However, there is a gap in published research, with the majority of mindfulness research focusing on middle-aged adults. Considering that mindfulness focuses on developing a connectedness between the mind and the body, it may be beneficial for older adults who experience both physical and psychological health problems. Previous studies have suggested that mindfulness-based therapies show promising results in reducing levels of depression, stress and anxiety in older adults. 13Therefore, it would be beneficial to provide mindfulness skills training to older adults, in order to investigate its potential for improving their general wellbeing.
This study aimed to add to the current research base and address the aforementioned gap in the literature by investigating older adult mental health service users’ experiences and perceived benefits of MBCT as a therapeutic intervention.
More specifically this study aimed to:
- Investigate whether participation in mindfulness groups improves older adults’ quality of life, self-compassion, depression, stress and mindfulness use;
- Evaluate the experiences and perceived benefits of older adults’ participation in a mindfulness group.
This study employed a repeated-measures, mixed-methods design. The quantitative strand of the study examined participants’ perceived levels of depression, self-compassion, stress, mindfulness use and quality of life at baseline and following eight weeks of MBCT. Qualitative data was collected via semi-structured interviews and thematic analysis was used to examine participants’ experiences of taking part in an MBCT group.
Participants were older adult service users who attend a Mental Health Service (N = 7). The group consisted of four females and three males. All participants were aged between 68 and 75 (mean age: 72; SD: 2.67). Eligible service users were given information about the nature of the group and its subsequent evaluation. All participants met with the group facilitators (Senior Clinical Psychologist and Assistant Psychologist) for a suitability screening. All participants had a psychiatric diagnosis (anxiety and mood disorders) and were deemed suitable to partake in the group by their Consultant Psychiatrist. Individuals with poor verbal communication skills or a hearing impairment were excluded, as were those with a neurocognitive disorder.
The following quantitative measures were used to collect information:
- The Geriatric Depression Scale (GDS).14
- The Quality of Life Scale (CASP-19).15
- The Five Facet Mindfulness Questionnaire Scale (FFMQ).16
- The Perceived Stress Scale (PSS).17
- The Self-Compassion Scale (SCS).18
The course involved attendance at eight weekly sessions for a duration of two hours. The MBCT course was based on the manual, “Mindfulness-Based Cognitive Therapy for Depression”. 4The content of the group consisted of psychoeducation combined with experiential mindfulness-based activities. The group involved various mindfulness practices while additional activities were given to work on at home, in order to practise incorporating mindfulness into daily life. Mindfulness diaries were given to record this and verbal feedback was given from participants each week.
Participants completed questionnaires pre-intervention and post-intervention. Semi-structured interviews were conducted within two weeks of the final group session. Interviews were recorded and transcribed by the researchers.
A realist inductive approach, a data driven approach to analysis which reports on the experiences of participants without trying to fit an existing coding frame or follow prior theoretical conceptions, was taken to analyse the transcripts. This was done in line with Braun and Clarke’s 19guidelines for thematic analysis. Therefore, the procedure was (1) data familiarisation, (2) generation of initial codes, (3) searching for themes, (4) reviewing themes, (5) naming themes, and (6) report production.
Quantitative data analysis (see Table 1) showed improvements in mood, as measured by the GDS (pre-group: mean = 7.14, SD = 5.27; post-group: mean = 5.14, SD = 3.44), increased levels of self-compassion, as measured by the SCS (pre-group: mean = 11.19, SD = 2.11; post-group: mean = 11.63, SD = 2.08), reduced stress levels, as measured by the PSS (pre-group: mean = 22.43, SD = 3.31; post-group: mean = 17.71, SD = 8.28), increased mindfulness use, as indicated by the FFMS (pre-group: mean = 107.14, SD = 19.26; post-group: mean = 124.00, SD = 17.94), and improvements in quality of life, as measured by the CASP-19 (pre-group: mean = 33.14, SD = 8.86; post-group: mean = 35.57, SD = 8.89). Although improvements were seen across all measures, results should only be viewed as illustrative, due to the limited sample size.
Table 1: Table Showing Mean Scores Pre-Group and Post-Group (Including Standard Deviation)
Geriatric Depression Scale
|Five Facet Mindfulness Scale||107.14||19.26||124.00||17.94|
|Perceived Stress Scale||22.43||3.31||17.71||8.28|
For explanatory purposes, the themes that arose from the data have been grouped into the following headings:
- Expectations for the group
- Overall group experience
- Benefits of MBCT
- On-going journey
Sub-themes that were identified within these themes will also be described.
- Expectations for the group
Participants reported seeking an alternative treatment option to medication and stated that they hoped to gain skills that they could use to help themselves in times of distress. Other participants reported feeling curious regarding the concept of mindfulness.
Hope for an alternative to medication
Participants’ responses indicated that they entered the group hoping for a treatment that could be used as an alternative to medication (“I was just looking for something that wasn’t medication that might help”). Others discussed the possibility that MBCT might be a useful component to be added to their treatment plan (“Nobody wants to be on medication forever, so I was looking for something extra that might help me in those agitating moments”).
Tools to add to personal resources
Participants reported that they sought skills they could develop independently and draw upon in times of distress (“I was just looking for some technique that might help me to get over those moments by myself”). The empowering aspect of gaining self-help skills was appealing to participants who wished “to find some technique that I could use on my own”.
Participants reported feelings of curiosity regarding the concept of mindfulness (“I wasn’t nervous. More curious. What were we going to do? What was it all about? So it was more curious … ‘cause I love doing new things”). Some participants had reportedly heard about mindfulness in the media, which sparked an interest into learning more about it(“I had heard about it, but I had no idea what mindfulness was and I was very curious to find out how to practise mindfulness and what it was all about”).
- Overall Group Experience
Participants reported a sense of universality, cohesion and hope as a primary experience felt from attending the group. Another theme that emerged was the acquisition of knowledge and the diverse skills learned. Finally, participants reported an overall experience of learning to become more mindful and fully present.
Universality, cohesion and hope
According to the participants, participation in the group provided a sense of universality for older adults who recognised that they are not alone in terms of their mental health struggles. This allowed them to normalise their personal journey and difficult thoughts and feelings. Participants reported valuing the views and opinions of other participants (“Each one of us had a different perspective on it”).Group discussions were an important aspect of the group, and the compassionate atmosphere of group members was highlighted (“Everyone helped each other”). Other individuals highlighted the openness of group members as insightful and valuable (“There was raw honesty”). Hearing the trials and triumphs of others appeared to provide hope for participants who were also going through a difficult period in their life (“It was inspiring to hear all the people telling their difficulties”).
Acquisition of knowledge
Participants reported that they acquired new knowledge during the MBCT group. For some individuals, the concept of eating mindfully resonated with them as a way to incorporate mindfulness into their everyday life (“To have a sultana in your hand for a few minutes and then eventually put it in your mouth. This is new. So I definitely did take that from the group, the mindfulness eating”).Other participants found the cognitive-behavioural teachings insightful (“It was all the different teachings about how thoughts are different to facts, and how your thoughts can affect how you feel. For me, that was felt in my tummy”). The application of these new skills in other areas of people’s lives was also highlighted(“It was nice to go home and try it out then”).
Getting into the mindful body
Participants described in detail their experiences of attempting to be more mindful and live in the present moment. While participants reported the difficulties associated with practising mindfulness, they acknowledged the benefits they experience when mindful (“Trying to stay in the moment is hard, but very good. I have a tendency to go away but it’s about focusing on anchoring myself to my breath when that happens”; “You get to a state of mind, you get to slow down”). Others found support in hearing similar struggles of other group members (“I was asking other people and people have distractions like I have”).
3. Benefits of MBCT
Participants found that the MBCT group has improved their ability to calm their thoughts and bear witness to painful emotions, as well as to be in the present moment. An increased awareness of the importance of practising gratitude and self-compassion was highlighted. Acceptance of the ageing process, as well as using MBCT as an alternative to medication, also emerged as a sub-theme.
Practice of being in the present moment
Participants reported that the MBCT teachings have allowed them to become more attuned to the present moment (“It’s about trying to keep yourself where you are. I have a tendency to go away”). Other participants reflected on the “mindful eating” teachings and highlighted how it has taught them to be more present in everyday activities (“Last week I was just eating for the sake of it and then I thought “mindful eating”. Slow down. Enjoy even two or three spoonful’s”; “The thought, food! Now, what else can I be making myself aware of? Fabric? Can I be mindful about fabric?”). Participants reported using mindfulness skills to calm their minds (“If I’m beginning to feel anxious in a particular situation, I do the three minute breathing. Doing that has got me so that I can stand there, rather than running out of there”).
Increased self-compassion and gratitude
Participants reported that following the MBCT group, they have experienced increased feelings of self-compassion, and are more aware of the importance of self-care. Participants viewed their newly acquired mindfulness skills as an important self-care tool in their on-going recovery (“If you’re not feeling good, I would recommend mindfulness for that reason. I would recommend it even if you are feeling good”; “Mindfulness has a lot of benefits in terms of looking after yourself”).Mindfulness practice has allowed participants to become more aware and grateful in the present moment (“Stopping for a moment and appreciating everything”). One participant stated that mindfulness has allowed her to be more present with her grandchildren (“I was with my grandkids, and realised that in the past I’ve always been somewhere else in my mind. And all of a sudden I was so grateful to be in the moment with them”).
Acceptance of the challenges of later life
Participants reported finding mindfulness helpful in coping with the ageing process. One participant explained that mindfulness has helped her to accept the complex difficulties associated with growing older (“At 65 you’ve been through most of your life, whether you like it or not. At my age illness and death are facing us and looking us in the face. Being able to accept things that I can’t change was an eye-opener for me”). Another participant found mindfulness helpful in coping with the bereavement of her husband(“Yeah, I use it at swimming. I always used to swim with my husband and obviously he’s not there now but I just went into the mindfulness. I just floated in the water, looked up to the sky and I used it there”).
A viable alternative to medication
Following the mindfulness group, several participants viewed mindfulness as more beneficial than taking medication (“It does outweigh for me taking medication … normally I’d be popping the pills down to try and calm down the legs”). Others stated that a benefit of MBCT is that they now have another option to draw upon that is not just medication (“Mindfulness is now another option for me”).
- On-going Journey
Post-group, participants reported that they hope to adopt mindfulness into their daily lives. Two perspectives were provided by participants of their intentions for future mindfulness practice; practising mindfulness every day and in response to a difficult situation.
Participants reported that mindfulness is a practice that, over the eight week course, they have incorporated into their everyday life (“It’s become a habit”).One participant explained that mindfulness has been able to ground her each day (“It is part of my day because it’s something to hold onto and I haven’t had something before to hold onto”). Other participants reported that they will practise mindfulness everyday as they view it as an important and vital component of their mental health (“Mindfulness is very, very important. It’s like brushing your hair or brushing your teeth”).
Participants recognised the benefits of practising mindfulness as a response to stressful periods. One participant explained that “If I feel stressed in the morning I do it. I will keep on doing it”.Another participant highlighted the relief of having these skills ready to use if their mood deteriorates (“And I have it now, so that I can use it, whenever, please God that I won’t ever go down that far again, but I can use it now at any stage”).
The results of this exploratory investigation indicated that MBCT appears to be a beneficial and positive psychological intervention for older adults attending an older adult mental health service. These preliminary findings suggest an improvement in the quality of life, self-compassion, depression, stress levels and mindfulness use following an eight week MBCT group. Qualitative findings highlighted the perceived benefits of an MBCT approach for older adults. As MBCT is recommended as a treatment option for recurrent depression in adults under the age of 65, 3this study suggests that MBCT should also be considered for older adults with similar mental health difficulties. Findings of this study are in line with other preliminary research conducted on the benefits of mindfulness practice for older adults.9,11In terms of its clinical application, considerations should be made regarding incorporating MBCT into the treatment plans of older adults attending an older adult mental health service. This would provide this population with an additional treatment option, granting more autonomy and choice for service users.
There are various limitations to this current study which warrant mentioning. Due to the sample population and the recommended group size, the study’s sample size is small, and findings should be taken as illustrative rather than representative. The sample consisted of a purposefully selected sample in one area of Ireland. Social desirability may have been a confounding factor as the researchers were known by the participants. Furthermore, participant bias may have been a confounding factor as participants self-selected for participation in the group and may have been more open to the intervention and change than other service users. No data was collected from a control group, and thus, no between-group comparisons can be made. It is difficult to ascertain the extent to which participants used mindfulness between sessions and therefore to make reliable inferences as to any relationship between improvements made and regularity of mindfulness practice.
Future research should take various routes. In order to gather reliable quantitative data, future studies should look at using a larger sample size. Longer post-group interviews (e.g. six months post-group) would provide valuable information on whether mindfulness practice and the benefits achieved from it, is maintained. The benefits of providing refresher groups should be ascertained, as well as establishing the cost-effectiveness of running groups within a health service setting. As this study looked only at older adults attending an older adult mental health service, the benefits of MBCT should be assessed for older adults in other settings (e.g. care homes), in order to assess its worth across differing populations. The role MBCT could have as an alternative to or in conjunction with medication should be discussed and assessed in more depth.
Ms. Mary-Frances McCafferty, Psychiatry of Old Age Team, Sligo. Corresponding author Email: firstname.lastname@example.org
Dr. Catherine Lee, Psychiatry of Old Age Team, Sligo.
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